29th Floor, Menara Dion, 27 Jalan Sultan Ismail, 50250 Kuala Lumpur, Malaysia.T : (03) 2026 9808, 2783 8383 F : (03) 2026 9708tokiomarine.com

Tokio Marine Insurans (Malaysia) Berhad (149520-U)

Information collected in this proposal form shall be used in connection with the Company’s purposes and course of business only.Maklumat yang diperolehi di dalam borang cadangan hanya boleh digunakan dengan tujuan dan untuk urusan perniagaan Syarikat sahaja.

Please write in block letters and tick () in the appropriate boxes. Kindly attach separate sheet if space is insufficient.Sila tulis dalam huruf besar dan tandakan () pada petak yang sesuai. Sila lampirkan kertas berasingan sekiranya kekurangan ruang.

Agent’s CodeKod Ejen ____________________

Cover Note No.No. Nota Perlindungan _____________________

Policy No.No. Polisi _____________________

Proposal Form/Borang Cadangan

Contractor’s All Risks

1. Title of contract (if project consists of several sections, specific section(s) to be insured)

2. Location of site

Country/province/district City/town/village

3. Name and address of Principal

4. Name(s) and address(es) of Contractor(s)

Tel. Nos.

5. Name(s) and address(es) of Subcontractor(s)1

6. Name and address of Consulting Engineer

7. Description of contract work2 (please give detailed techincal information) Dimensions (length, height, depth, spans, number of floors)

Foundation (method, level of deepest excavation)

Construction methods

Construction materials

8. Is the Contractor experienced in this type of work or construction methods? Yes No

1 If necessary on a separate sheet. 2 For harbours, piers, docks, tunnels, galleries, dams, roads, airports, railway facilities, sewerage and water supply systems, bridges and

structures in earthquake zones also see special questionaires.

GST Registration No.

For Office Use

Policy No.

Cover Note No.

Rate

Premium

Warranties

Agency

App. By

D D M M Y Y Y Y

GST Registration Date

Contractor’s All Risks 11/2016

9. Period of Insurance

Commencement of work

Duration of construction Months

Date of completion

Maintenance period Months

10. Work to be carried out by Subcontractors

11. Special risks Fire, explosion Yes No

Flood, inundation Yes No

Landslide, storm, cyclone Yes No

Blasting Yes No

Other

Volcanism, tsunami Yes No

Have earthquakes been observed in this area? Yes No

If so, please state intensity Magnitude

Is the design of the structures to be insured based on regulations regarding Yes No earthquake-resistant structures?

Is the design standard higher than that stipulated in the relevant regulations? Yes No

12. Subsoil conditions rock gravel sand clay filled ground

Other

Do geological faults exist in the vicinity? Yes No

13. Ground-water level Level below grade m

14. Nearest river, lake, sea, etc, Name

Distance

Levels low water mean water

Highest level recorded Date

15. Meteorological conditions Rainy season from to

Max. rainfall (mm) per hour per day per month

Storm hazard minor medium high

16. Are extra charges for overtime, nightwork, work on public holidays to be included Yes No Limit of Indemnity

17. Is Third Party Liability to be included? Yes No

Has the Contractor concluded a separate policy for TPL?

Limit of Indemnity

18. Details of existing buildings or surrounding property possibly affected by the contract work, such as by excavating, underpinning, piling, vibration, ground-water lowering, etc.

19. Are existing buildings and/or structures on or adjacent to the site, owned by or Yes No held in care, custody or control of the Contractor(s) or the Principal, to be insured against loss or damage arising out of or in connection with the contract works?

Limit of Indemnity

Exact description of these buildings/structures

20. Please state hereunder the amounts you wish to insure and the limits of indemnity required (of Policy Wording, Section I, Memo I, and Section II)

Currency:

Section I Material Damage

Section IIThird PartyLiability

Sums to be Insured

Limits of Indemnity3

Limits of Indemnity4

Items to be insured

1. Contract work (permanent and temporary work, including all

material to be incorporated herein)

1.1 Contract price

1.2 Materials or items supplied by the Principal(s)

2. Construction plant and equipment

3. Construction machinery (please attach list showing replacement values of

new items)

4. Clearance of debris (insured only up to the amount indicated)

Total sum to be insured under Section I

Special risks to be insured

Earthquake, volcanism, tsunami

Storm, cyclone, flood, inundation, landslide

Items to be insured

1. Bodily injury

1.1 any one person

1.2 total

2. Property damage

Total limit to be applied under Section II

3 Limit of indemnity in respect of each and every loss or damage and/or series of losses or damages arising out of any one event.

4 Limit of indemnity in respect of any one accident or series of accidents arising out of any one event.

D D M M Y Y Y Y

Verification of Identity / Pengesahan Pengenalan

In compliance with Section 16(2) of the Anti-Money Laundering Act 2001I hereby certify that the Proposer’s original NRIC/Business Registration Certificate was verified and authenticated by me at the point of sales.

Selaras dengan pematuhan Seksyen 16(2) Akta Pencegahan Pengubahan Wang Haram 2001Saya dengan ini mengesahkan bahawa Kad Pengenalan/Sijil Pendaftaran Perniagaan asal pemohon telah disahkan ketulenannya semasa urusniaga dijalankan.

Third party verification / Pengesahan pihak ketiga

“Third party” means insurance agents, insurance brokers or staff of insurance companies.“Pihak ketiga” bermaksud ejen insurans, broker insurans atau kakitangan syarikat insurans.

Note : To maintain a copy of NRIC for applicants for individual insurance policies where the premium is more than RM50,000.Nota : Sesalinan KP perlu disimpan bagi pemohon yang mengambil polisi insuran individu dimana premiumnya melebihi RM50,000.

Name / Nama

NRIC no. / No. Kad Pengenalan

Signature / Tandatangan

Date / Tarikh

Tokio Marine Insurans (Malaysia) Berhad is licensed under the Financial Services Act 2013 and regulated by Bank Negara MalaysiaTokio Marine Insurans (Malaysia) Berhad dilesenkan di bawah Akta Perkhidmatan Kewangan 2013 dan dikawalselia oleh Bank Negara Malaysia

Important Notices / Notis Penting• Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for a purpose related to your trade, business

or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. / Menurut Perenggan 4(1) Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda memohon insurans ini untuk tujuan yang berkaitan dengan perdagangan, perniagaan atau profesion anda, anda berkewajipan untuk mendedahkan apa-apa perkara yang anda tahu akan mempengaruhi keputusan kami dalam menerima risiko dan menentukan kadar dan terma yang dikenakan, dan apa-apa perkara yang munasabah yang boleh dijangka, jika tidak ia boleh menyebabkan pembatalan kontrak insurans, keengganan atau pengurangan ganti rugi, perubahan terma atau penamatan kontrak insurans anda.

• The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. / Kewajipan pendedahan di atas hendaklah diteruskan sehingga kontrak insurans anda dimeterai, diubah atau diperbaharui dengan kami

• You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this Proposal Form is inaccurate or has changed. / Anda juga mempunyai kewajipan untuk memberitahu kami dengan serta-merta jika pada bila-bila masa selepas kontrak insurans anda ditandatangani, diubah atau diperbaharui dengan kami, apa-apa maklumat yang dinyatakan dalam Borang Cadangan ini tidak tepat atau telah berubah.

Acknowledgement & Declaration / Perakuan & PengisytiharanPersonal Data Protection Act 2010 (PDPA) Notice/Notis Akta Perlindungan Data Peribadi 2010

I/We acknowledge and consent that the personal data, including any sensitive personal data, collected herein be used, processed and disclosed for the purpose of this proposal to reinsurers; individuals or organizations associated with Tokio Marine Group, or any selected third party (within or outside Malaysia). I/We acknowledge that I/we am/are obligated to provide the above personal data failing which my/our proposal could not be processed and that I/we am/are entitled to obtain access to, request for correction of or limit the processing of my/our personal data; andSaya/Kami mengakui dan bersetuju bahawa data peribadi, termasuk apa-apa data peribadi yang sensitif, yang dikumpulkan di sini digunakan, diproses dan dizahirkan untuk tujuan cadangan ini kepada penanggung insurans semula; individu atau organisasi yang berkaitan dengan Kumpulan Tokio Marine, atau sebarang pihak ketiga (di dalam atau di luar Malaysia). Saya/Kami mengakui bahawa saya/kami perlu memberikan data peribadi di atas, dan jika gagal berbuat demikian, cadangan saya/kami tidak dapat diproses dan saya/kami berhak untuk mendapatkan akses kepada, meminta pembetulan atau mengehadkan pemprosesan data peribadi saya/kami; dan

I/We further agree that you may disclose and share my/our information with individuals or organizations associated with Tokio Marine Group, strategic partners and other third parties (within or outside Malaysia) as the Company deems fit for the purpose of cross-selling, promoting and marketing financial products and services offered by you and the other entities.

Saya/Kami juga bersetuju bahawa anda boleh mendedahkan dan berkongsi maklumat saya/kami dengan individu atau organisasi yang berkaitan dengan Kumpulan Tokio Marine, rakan strategik dan pihak ketiga lain (di dalam atau di luar Malaysia) yang difikirkan patut untuk tujuan jualan silang, promosi dan pemasaran produk dan perkhidmatan kewangan yang ditawarkan anda dan entiti-entiti lain.

Protection of your privacy is very important to us. Please visit our website at “www.tokiomarine.com” to view our Privacy Statement.Perlindungan privasi anda adalah sangat penting bagi kami. Sila layari laman web kami di “www.tokiomarine.com” untuk melihat Penyata Privasi kami.

Declaration/Pengisytiharan

I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal Form and I/we hereby declare that I/we have fully and accurately answered the questions above. Saya/Kami faham bahawa menjadi tanggungjawab saya/kami untuk mengambil langkah yang munasabah untuk tidak salah nyata semasa menjawab soalan-soalan dalam Borang Cadangan ini dan saya/kami dengan ini mengaku bahawa saya/kami telah menjawab dengan sepenuhnya dan dengan tepat soalan di atas.

D D M M Y Y Y YDate / TarikhSignature of Proposer

Tandatangan Pemohon Insurans